Self Billing Statement Record Layout (PPP562/565) As of Release /04/13
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1 Record Type Summary Record Type Indicator Record Type Description Comments Column 1-2 = '01' Employee Record Column 1-2 = '02' Life Insurance Column 1-2 = '03' Disability Column 1-2 = '04' AD&D Column 1-2 = '05' Postdoc Supplemental Disability Column 1-2 = '06' Postdoc Life/AD&D Column 1-2 = X'FF' Trailer
2 Self Billing Record Type 1 Employee Record Record Type Value '01' 6-10 Coverage Period Plan Code Plan Description Coverage Code Employee Count Premium Rate Premium amount or literals COV END or WAIVED Premium Paid May be a negative amount End of Record 1 Flag Value constant X Filler
3 Self Billing Record Type 2 Life Insurance Record Type Value '02' 6-10 Coverage Period Plan Code Value LI Plan Description Value Prudential * Coverage Code Coverage Description Control Group from CPWSXIC Employee Count Premium Rate Or literal PER INDIVIDUAL Premium Paid May be a negative amount End of Record 2 Flag Value constant X Filler
4 Self Billing Record Type 3 Disability Position Length/ Field Description Data Comments Location Coverage Period CCYY-MM-DD Plan Code Value DI Plan Description Value Liberty Mutual * Benefit Values are: STD, STD/TD, EPD Plan Values are: UPC, EPD7, EPD30, EPD90, EPD180 or blank Class Values are 'UP00', 'E007', 'E0030', 'E0090', 'E0180', UP13, E137, E1330, E1390, E13180, or spaces Control Group From CPWSXIC Employee Count Premium Rate Premium rate or " PER 99 INDIVIDUAL" Premium Paid May be negative amount End of Record Flag Value constant 'X'
5 Self Billing Record Type 4 AD&D Record Type Value '04' 6-10 Coverage Period Plan Code Value AD Plan Description Value American Home * Coverage Code Coverage Description Control Group from CPWSXIC Employee Count Premium Rate Premium rate or " PER INDIVIDUAL" Premium Paid May be negative amount 11 1 End of Record 4 Flag Value constant X Filler
6 Self Billing Record Type 5 Postdoc Supplemental Disability Record Type Value '05' 6-10 Coverage period Plan code Value 'PD' Plan desc Value ' Standard Life' * Benefit Values are 'STD' or ' LTD/TD' EPD plan code Values are 'UPC' or spaces Class Values are 'UP00' or spaces Control group from CPWSXIC Emp count Premium rate Premium rate or " PER INDIVIDUAL" Premium paid May be negative amount End of Record 5 Flag Value constant 'X' Filler
7 Self Billing Record Type 6 Postdoc Life/AD&D Record Type Value '06' 6-10 Coverage period Plan code Value 'PL' Plan desc Value 'Standard Life' * Coverage code Coverage desc Control group from CPWSXIC Emp count Premium rate Premium paid End of Record 6 Flag Value constant X Filler
8 Self Billing Record - Trailer Record Type Value x'ff' Total Records Medical Count Supplemental Life Count Supplemental Disability Count Accidental Death and Dismemberment Count Postdoc Supplemental Disability Count Postdoc Life/AD&D Count Filler
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PPP5623/PPP562 /020105 UNIVERSITY OF CALIFORNIA-SYSTEMWIDE PAGE NO. 000001 PLAN CODE: D1 Delta Dental PPO COVERAGE PERIOD: SEPTEMBER 2016 Self 311 42.24 13136.64 W/Adult 44 79.15 3482.60 W/Childrn 26 86.87
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